The ACP Advocate Blog

by Bob Doherty

Friday, December 23, 2011

Congress Passes Two Month "Doc Fix"

House and Senate this morning passed bill to extend current Medicare payments to doctors through February. So no 27.4 percent cut, for now. But will be back with the same old, same old in 2012. More brinkmanship while holding doctors and patients hostage. So . . . Happy New Year!???! With that, I am signing off from blogging until after January 2 and thinking about anything but Congress! Best wishes for holiday peace and joy to all of you.

Bob

Thursday, December 22, 2011

Deal reached to prevent Medicare doc pay cut

A few minutes ago, Speaker Boehner announced that the House and Senate have agreed on a two month extension of current Medicare payment rates, the payroll tax cut, and unemployment benefits.

My understanding is that the agreement has the House accepting the Senate's proposal to extend the payroll tax break, unemployment insurance benefits, and current Medicare payment rates through the end of February, along with an agreement with the Senate to appoint a House-Senate conference committee to begin negotiations on a longer-term extension. It remains unclear exactly when the votes in the House and Senate will take place, and at least in the Senate, it will require unanimous consent by all Senators. If it passes both the House and Senate, the bill is expected to go to President Obama for his signature no later than December 30. Once signed into law, the legislation would prevent the 27.4% cut in Medicare paymentsto physicians resulting from Medicare's Sustainable Growth Rate (SGR) formula.

While ACP has strongly urged Congress to block the cut, stating that it would be unacceptable for Congress to recess and allow the cut to go into effect, this short-term extension does not represent the permanent solution that ACP believes is necessary. Accordingly, ACP will continue to urge Congress to enact a permanent solutionthat stabilizes payments for at least five years and allows for the transitionto better payment models.

Keep in mind that until the legislation actually passes the House and Senate, no one can guarantee with absolute certainty that the 27.4% SGR cut won't go into effect. However,the official announcement of the deal makes it very likely that the cut won't go into effect--at least for the next two months. After that, who knows?

A Very Boehner Christmas

In keeping with a tradition that I started with my first late December blog in 2008, I have taken the liberty of penning a tongue-in-cheek parody of a beloved Christmas story. It seemed fitting this year to imagine Speaker John Boehner’s Night Before Christmas, ruminating about the flak he is getting for not being able to reach a deal with Harry Reid and the Senate. (This is all intended as purely non-partisan fun, so please, please, take it in the spirit of holiday cheer and don’t take offense). Here it goes:

A Very Boehner Christmas

Twas the night before Christmas, when all through the House
Speaker Boehner was fuming, “Harry Reid is a louse.”
“I’ve sent him our bills to cut ObamaCare,
Yet the Senate acts like we’re not even there!

While Reid and McConnell lay all snug in their beds,

The Tea Party Caucus keeps demanding my head!
To show them I am not Obama’s sap
I even went along with their debt ceiling crap,

But if you listen to Washington’s talking heads chatter,
Nothing I do, really does matter.
As long as the Senate sends our bills to the trash,
It is MY leadership that they continue to bash!

Meanwhile, Gingrich is campaigning in the New Hampshire snow
But who can tell how this election will go?
To my wondering eyes its appears,
Gingrich as President, many doth fear,
But Romney comes across as bit too slick,
Who will the GOP decide is their pick
to rid us off Obama and his big government fix?”

And Boehner whistled, and shouted, and called them by name;
"Now, Bachmann, now Romney, now Huntsman and Perry!
On, Newt! on Mitt! Help make Christmas Merry!
Take us to the top of the polls! Don’t let us stall!
We must win the White House and Senate, we must have it all!"

As dry leaves that before the wild hurricane fly,

When they meet with an obstacle, mount to the sky,
So Boehner checked in first class and flew,
Back to Ohio, to the people he knew.

But the people at home were strangely aloof
They wouldn’t let him under their Country Club roof.
“A doctor,” they said, “is nowhere to be found,
Because you let their fees go way, way down,”
“Congress,” they said, “doesn’t give a hoot,
So in November, maybe, we’ll give you the boot!”

But Boehner stood his ground against the unhappy pack,
Oh, his frown -- how it wrinkled! His face wasn’t merry!
He looked like he’d eaten a too-sour cherry!
His tight little mouth was drawn up like a bow,
And he told them all something they needed to know,
“It’s Obama’s fault, you know, he’s the one who must go!

(While smoke encircled his head like a wreath
From a cigarette he had clenched in his teeth),
And then, well, Boehner became his happy old self
In the end, he knew, they’d thank him, for protecting their wealth.

With a wink of his eye and a twist of his head,
He said that Republicans had nothing to dread;
As long as millions remain out of work,
They’ll vote out the Democrats, every last jerk,

And laying his finger aside of his nose,
And giving a nod, and after one last pose;
He sprang to his car, to his driver gave a whistle,
And away they drove off, like the down of a thistle.
But they heard him exclaim, 'ere he drove out of sight,
"Happy Christmas to all (of the top 1 percent), and to all a good-night."


With that, I will be taking the next week or so off from blogging to spend time with my family, unless something really, really happens (like a Christmas miracle to stop the SGR cut) that demands commentary. I wish all of you a joyful holiday and New Year, and especially thank those of you who spend your time reading this blog and sharing your own opinions.

Today’s question: No question, just Happy Holidays!

Wednesday, December 21, 2011

“Least Popular Congress in History” Leaves Patients Holding the Bag

With the U.S. Senate and most House members having left Washington for the holidays, the 27.4% cut in Medicare payments to doctors will almost certainly go into effect on January 1. Although it remains theoretically possible that Congress could return next week to reach a deal, the House and Senate are so dug into their sides that I don’t expect that to happen.

More likely, the SGR will be dealt with when Congress returns in January, at which point it is likely to enact a “fix” retroactive to January 1. Problem is, the Senate isn’t scheduled to return to Washington until January 23, the day when Medicare will have to start processing claims with the 27.4% cut. (Medicare by law can only hold them for 14 business days from the date of service.) Congress could decide to return earlier and find some other way to take action before the cuts have to be processed, but in the meantime physicians should prepare themselves for the possibility that the 27.4% cut will happen, at least for services provided during the first week of January.

It isn’t just physicians who are being left in the lurch, of course. The impasse means that payroll taxes will go up for just about everybody, and unemployment benefits will be cut off for many. And this isn’t the first time that this Congress has failed to do its job.

Roll Call reports that “the level of dysfunction that has characterized the 112th Congress may be unparalleled. Aside from passage of trade agreements in September and a handful of minor policy bills, virtually the only bills that have made it to President Barack Obama’s desk have either been appropriations measures, the most basic function of Congress, or emergency stopgap bills to avert government shutdowns or credit downgrades. And even those have come only after Congress took itself and the nation to the brink of collapse. The reasons for the dysfunction are varied, from gridlock in the closely divided Senate to Boehner’s increasing difficulty in managing the expectations and actions of his unruly conference. But regardless of the reason why, lawmakers acknowledge they have reached a new low.”

Is it any wonder that Gallup reports that this Congress is the least popular in history?

I know that the SGR cut will lead some ACP members to question the effectiveness of ACP’s advocacy, and I am always open to ideas on what we might do differently.

But here is how I see it. ACP has cajoled, lobbied, pressured, proposed and used every argument and ethical tactic we could think of to get Congress to do the right thing and eliminate the SGR. (The one tactic we will not use is to support a physician boycott or strike, a violation of ACP’s code of ethics.)

We offered specific ideas to end the SGR, stabilize payments, and transition to new models that recognize the value of internists' care. We even told Congress how to pay for it. We have built coalitions with other medical organizations, AARP, and other stakeholders. And this time, we decided we would not be pulled into helping Republicans or Democrats, House or Senate, get votes for another short term fix paid for by deeper cuts next time. That tired script hasn't worked before and won't work now.

What we can't do, that no one organization can do, is fix a broken Washington where compromise is considered a deadly sin, where partisanship and ideology trump common sense, where brinkmanship and gridlock is the norm. Only voters can do that by electing people committed to making the system work again.

Today’s question: How would you fix a broken Washington?

Monday, December 19, 2011

An Unwelcome Holiday Tradition

Waiting until the last moment for Congress to stop the next Medicare SGR cut has become an established holiday tradition, right along with trimming a Christmas tree or lighting a Menorah. This December tradition, though, is anything but welcome. During this supposed season of joy, why must doctors and patients be left waiting to know whether Congress will enact legislation in time to prevent a January 1 cut of more than 27 percent?

Last week, I blogged that “the odds still favor an agreement to stop the 27.4% SGR cut, although the issue may not be decided until after Christmas—just days before it is scheduled to go into effect.” Now, I am not optimistic at all. Over the weekend, Congress navigated itself into another partisan dead end, making it much more likely—with each passing day—that no agreement will be reached in time to avert the 27.4% New Year cut.

Here is what happened.

Last week the House passed a bill, as part of a broader “extenders” package, to prevent the Medicare cuts for two years, replacing them with a small positive update. The House bill, though, included budget offsets and policy riders that were unacceptable to the Senate and White House. On Saturday, the Senate passed a short-term patch, as part of its extenders bill, which would have extended current Medicare payment rates for only two months. Today, the leadership of the House of Representatives stated that the Senate bill is unacceptable, and that it instead would seek an agreement on a year-long extension of Medicare payment rates and other expiring provisions. Yet the House has not presented a plan or process to resolve its differences with the Senate.

If the Senate bill is voted down tonight by the House, as is now expected, there is no clear path forward that would allow Congress to act before the 27.4% cut goes into effect on January 1. The Senate has already recessed for the year, and Majority Leader Reid has vowed not to bring it back to negotiate with the House unless the House agrees to the Senate’s two-month extension. If he doesn’t yield, and Speaker John Boehner doesn’t yield on the House’s insistence that the House and Senate agree to a new plan, there is no viable way to prevent the 27.4% cut before it goes into effect on January 1.

As it has done in past years, Congress could return in January and try to enact a “fix” that is retroactive to January 1, with CMS holding claims (as it is required to do for 14 business days anyway) in the meantime. But with the Senate not scheduled to return to Washington until January 23, this allows no time for Congress to enact a retroactive fix before CMS would have to instruct its carriers to begin paying at the reduced rate, on or around the same day that the Senate returns. Beyond that date, CMS would have to begin paying interest on any delayed claims.

Sure, Congress could return sooner in January, or better yet, there may be some way for it to find a solution prior to January 1. But I wouldn’t bet on it.

ACP, for its part, released a statement today blasting Congress for the disarray and dysfunction that is jeopardizing care for millions.

Congress’ failing to stop the SGR cut is the equivalent of the proverbial coal in your stocking, or the Grinch who stopped Christmas from coming. Only unlike the Grinch, there seems little chance that Congress’ “small heart will grow three sizes larger” so that it brings back what the SGR has taken from doctors and their patients.

Today’s questions: What will you say to your Representative or Senators if Congress allows the 27.4% SGR cut go into effect? What will you say to your patients?

Wednesday, December 14, 2011

The Medicare SGR and Charlie Brown’s Football

An iconic symbol of hopeful—or hopeless—futility is Charlie Brown lining up, year after year, to kick the football placed by his devious friend Lucy—only to have her pull it away at the last minute. Physicians know how Charlie Brown feels. Each year, Congress offers doctors a football called SGR repeal, only to pull it away from them in the end.

This year, it was the House Energy and Commerce Committee, Republicans and Democrats alike, who told medicine on March 28 that this year would be different, that Congress—really, really, promise, promise—was going to repeal the Medicare SGR formula and replace it with a better system. Here is what chairman Fred Upton (R-MI) and ranking member Henry Waxman (D-CA) wrote to the doctors:

“Unless we begin the process of developing a long-term solution, we will once again be faced with the unwanted choice of extending a fundamentally broken payment system or jeopardizing access to care for Medicare beneficiaries. We cannot let either happen.”

Medicine answered the call by offering Congress concrete ideas for stabilizing payments for the next five years and transitioning to a better payment system for patients and their physicians.

Well, we now know how all that turned out. Here we are, just 17 days before Medicare payments to physicians will be cut by 27.4%, and Congress still hasn’t figured out how to stop the cut, never mind enact a long-term solution.

Last night, the House of Representatives passed a bill that would replace the SGR cuts with one percent annual increases in 2012 and 2013, but it does not repeal the SGR or result in a long-term solution. It is paid for by controversial Medicaid and Medicare payment cuts to hospitals for indigent care and outpatient facilities, increased Medicare premiums to higher income beneficiaries, reductions in funding for prevention and wellness programs, and money that is set aside to pay for health insurance subsidies created by the Affordable Care Act—cuts that are being fiercely contested by hospitals, AARP, and the American Cancer Society-Cancer Action Network, among others. The SGR provision is just one part of a broader package that would extend unemployment benefits and the expiring Social Security payroll tax cut, but it includes other policies that are so strongly opposed by the White House and Senate Democrats that it is considered to be “dead on arrival” in the Senate.

What happens when the GOP bill fails in the Senate, as expected? Negotiations likely will take place over the weekend between Senate Democrats and House Republicans on a compromise package, but no one knows if they will be able to reach a deal that can pass both chambers before the SGR cut goes into effect and the payroll tax cut and unemployment benefits expire on January 1. The odds still favor an agreement to stop the 27.4% SGR cut, although the issue may not be decided until after Christmas—just days before it is scheduled to go into effect.

It’s enough to make you want to shout “Good Grief!”

Of course, it isn’t fair to put all of the blame on the current Congress. Remember, the Democratically-controlled 111th Congress failed on multiple occasions to pass more than short term (sometimes just weeks or months) patches to prevent scheduled SGR cuts, and in June 2010, it actually allowed the cut to go into effect for several weeks, during which CMS held Medicare claims until Congress got around to passing another temporary reprieve.

Much of the same can be said about the 110th Congress, and the 109th, and the 108th, and the 107th . . . all of whom enacted short-term reprieves to prevent scheduled SGR cuts but could not come up with a permanent solution. As much as physicians wanted a permanent solution, their professional associations usually ended up helping Congress get the votes for a temporary patch because the consequences for patients of allowing the SGR cut were too dire.

Not this time, though: ACP (and most other physician organizations) are telling Congress that although it is imperative that they act, before recessing for the year, to reach agreement on a viable bipartisan approach to prevent the SGR cuts, we cannot endorse a bill that just results in another temporary reprieve from the SGR cuts resulting in even deeper cuts in future years. Instead, Congress must enact comprehensive and long-term payment reform that eliminates the SGR, provides stable payments for all physician services for at least five years, and establishes a transition to better payment models.

Sure, Congress isn’t likely to reach agreement on a long-term SGR solution before it recesses for the year—although a Christmas miracle to that effect would nice! Another short-term fix is much more likely. But if Congress once again chooses “. . . the unwanted choice of extending a fundamentally broken payment system or jeopardizing access to care for Medicare beneficiaries” it is doing it without the help of organized medicine. Medicine is willing to line up (again) to kick a football called SGR repeal, but only if it really has a chance of getting over the goal post.

Today’s question: Do you agree that physicians should withhold support from any SGR bill that provides a temporary reprieve from the 27.4% cut if it results in deeper cuts in subsequent years, and doesn’t move toward a permanent solution?

Thursday, December 8, 2011

Liberal doctors’ wrong-headed critique of the IOM

If conservatives can be faulted for believing that the “free market” alone is capable of making health care more affordable and available —all evidence to the contrary— then liberals must be faulted for believing that the government is capable of offering “free” health care for all, without regard to cost. Case in point: liberal doctors’ broadside against the Institute of Medicine (IOM) for having the audacity to propose that cost be considered in determining health insurance benefits.

The IOM, at the request of the Department of Health and Human Services, convened a panel of experts to advise the department on the benefits to be offered through state health exchanges created by the Affordable Care Act (ACA). The IOM committee proposed a framework that would consider the population’s health needs as a whole; encourage better care by ensuring good science is used to inform practice decisions; emphasize judicious use of resources; and carefully use economic tools to improve value and performance. It recommended that “the initial EHB package be equivalent in scope to what could be purchased by the average premium that a small business would pay on behalf of an employee” writes John Iglehart in the New England Journal of Medicine, because if “a more expansive package” is offered, “many currently uninsured individuals and small businesses would find it unaffordable, which would undermine the overriding goal of the reform law — to make coverage both meaningful and nearly universal.”

This seemingly common sense thinking was enough to make the Physicians for a National Health Program (PNHP) turn apoplectic. In a letter circulated by the PNHP, some 2400 doctors claimed that the IOM’s report would result in “skimpy” and “bare-bones” policies that would “saddle enrollees with unaffordable co-payments and deductibles.” The letter went on to attack the integrity of the IOM’s expert panel, accusing its members of being “riddled with conflicts of interest . . [and] . . .having amassed personal wealth through their involvement with health insurers and other for-profit health care firms.”

(Regrettably, this type of ad hominem accusation has become a staple of what passes for political debate these days, from all across the political spectrum. It is not enough to disagree with someone, you have to say that they are motivated by greed, avarice, or some other reprehensible motive.)

Unlike the PNHP, the American College of Physicians believes that IOM has found the right balance between expanding coverage and keeping it affordable. ACP believes, as does the IOM, that there must be a transparent and publicly acceptable process for making health resource allocation decisions with a focus on medical efficacy, clinical effectiveness, and need, with consideration of cost based on the best available medical evidence. (Click here to read a side-by-side comparison between the IOM’s recommendations and ACP policy.)

I trust that the liberal doctors who signed onto the PNHP letter really want what is best for patients and sincerely worry that the benefits that would be offered under the IOM’s framework would be inadequate for many. Fair enough—although I think the unfair and unwarranted attack on the IOM’s credibility undermines the letter-writers’ credibility more than it does the IOM’s. But I also believe that it is fanciful to pretend that the government can guarantee that everyone will have access to health insurance benefits, to be paid for by taxpayers, employers, and employees, without explicitly taking into account the cost of those benefits and making a determination on what we, as a society, can realistically afford. Guaranteed coverage that does not pay attention to cost will be coverage that no one can afford—not the vision of accessible, affordable health care for all that the PNHP says is its goal.

Today’s questions: Do you agree with the IOM that costs should be considered in determining essential benefits? Or with the PNHP’s view that this will result in “skimpy” and “bare-bones” coverage?

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About the Author

Bob Doherty is Senior Vice President, American College of Physicians Government Affairs and Public Policy; Author of the ACP Advocate Blog

Email Bob Doherty: TheACPAdvocateblog@acponline.org.

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